AP-Physiology
Exercise Physiology Service Enquiry + Pre-Screen
Full Name
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First Name
Last Name
Phone Number and Email
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Phone Number
Email- example@email.com
Local Suburb
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Example- Hillarys
Date of Birth
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Day
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Month
Year
Day / Month / Year
Health & Injury History
Do you have any injuries, past or current?
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Shoulders
Back
Hips
Knees
Ankles
Arms
No Injuries
Other
Do the injuries previously mentioned impact your exercise? (If yes, please provide as much specific detail of your injury as you know.)
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Have you been told that you have any of the below by a health professional?
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High Blood Pressure
High Cholesterol
Asthma
Arthritis
Diabetes
Osteoporosis
None of the above
Other
Exercise History & Goals
Consent and Private Health
What are your primary health goals?
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Are there any current obstacles that would prevent you from reaching your goals?
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Do you have a Referral? Please state type of Referral below (example: Medicare)-
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From your GP/Specialist/Other.
Do you give consent for one of our Exercise Physiologists to contact you, and also give consent for any recommended exercises or treatment that may be discussed with you?
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Verbal consent to treatment will be discussed in person.
Private Health Fund Provider?
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Gym Access Disclaimer
Your responses help us build the most appropriate treatment pathway for you.
Exercise Treatment will be tailored specific to your needs or requirements. If clinically recommended, gym-base exercise may be advised. AP-Physiology conducts majority of services through GoodLife Health Clubs gyms. Initial consultations can be complete without paying fees or a gym membership, however facilities may require payment of a casual fee, or an active membership for any continued access. Do you currently have an active gym membership, are you looking to get enrolled into a membership, or will you be seeking home/other treatment options?
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Don’t have a Gym Membership, but will be considering one for continued treatment.
Don’t have a Gym Membership, and want to explore other/home treatment options.
Currently have active Gym Membership, with the GoodLife Health Clubs Gyms.
Currently have active Gym Membership. (Please select other, and state where.)
Other
What are your available days and times to perform exercise?
How did you learn or hear about us as an Exercise Physiology business?
Have you considered a budget for achieving your health/fitness goals? ($ per week)
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Submit
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